Apparatus for removing intact cells from a surgical site

ABSTRACT

A surgical treatment apparatus comprises a waterjet configured to fragment tissue and provide intact cells such as stem cells with the fragmented tissue. The intact cells can be used in one or more of many ways such as for genetic or other testing, and the intact cells can be identified as stem cells. In many embodiments, the intact cells comprise stem cells. In many embodiments, a waterjet is configured to fragment tissue. The fragmented tissue can be collected with a filter having pores sized smaller than the tissue fragments. In many embodiments cavitation with a waterjet is used to fragment the tissue comprising the intact stem cells. The waterjet may comprise a waterjet immersed in a liquid comprising water so as to form a plurality of shedding pulses. The plurality of shedding pulses can be generated with a frequency sufficient to fragment the tissue. The shedding pulses can generate cavitations that fragment the tissue.

CROSS-REFERENCE

The present application is a divisional of U.S. application Ser. No.15/446,749, filed Mar. 1, 2017, entitled, “GENE ANALYSIS AND GENERATIONOF STEM CELL METHODS AND APPARATUS”, which is a continuation ofInternational Application No. PCT/US2015/048687, filed Sep. 4, 2015,entitled “GENE ANALYSIS AND GENERATION OF STEM CELL METHODS ANDAPPARATUS”, which claims priority to U.S. Provisional Patent ApplicationNo. 62/046,290, filed Sep. 5, 2014, entitled “GENE ANALYSIS ANDGENERATION OF STEM CELL METHODS AND APPARATUS”, the entire disclosuresof which are incorporated herein by reference.

The subject matter of the present application is related to:International Patent Application No. PCT/US2013/028441, filed Feb. 28,2013, entitled “AUTOMATED IMAGE-GUIDED TISSUE RESECTION AND TREATMENT”;U.S. Provisional Patent Application No. 61/874,849, filed Sep. 6, 2013,entitled “AUTOMATED IMAGE-GUIDED TISSUE RESECTION AND TREATMENT”; U.S.Provisional Patent Application No. 61/972,730, filed Mar. 31, 2014,entitled “AUTOMATED IMAGE-GUIDED TISSUE RESECTION AND TREATMENT”; U.S.Provisional Patent Application No. 62/019,305, filed Jun. 30, 2014,entitled “AUTOMATED IMAGE-GUIDED TISSUE RESECTION AND TREATMENT”; U.S.Provisional Patent Application No. 62/018,359, filed Jun. 27, 2014,entitled “TISSUE SAMPLING AND TREATMENT METHODS AND APPARATUS”; U.S.Provisional Patent Application No. 62/019,299, filed Jun. 30, 2014,entitled “FLUID JET TISSUE ABLATION AND INDUCED HEMOSTATIS (AQUABLATION)METHODS AND APPARATUS”; the entire disclosures of which are incorporatedherein by reference.

The subject matter of the present patent application is also related to:U.S. patent application Ser. No. 12/700,568, filed Feb. 4, 2010,entitled “MULTI FLUID TISSUE RESECTION METHODS AND DEVICES”, now U.S.Pat. No. 9,232,959,959, issued Jan. 12, 2016; and International PatentApplication No. PCT/US2011/023781, filed Feb. 4, 2011, published as WO2011/097505 on Nov. 8, 2011, entitled “MULTI FLUID TISSUE RESECTIONMETHODS AND DEVICES”; the full disclosures of which are incorporatedherein by reference.

BACKGROUND

The field of the present invention is related to the sampling of cellsand tissue and treatment of tissue, and more specifically to thesampling and treatment of an organ such as the prostate.

Prior methods and apparatus of treating subjects such as patients canresult in less than ideal results in at least some instances. Forexample, prior methods of prostate surgery can result in longer healingtime and less than ideal outcomes in at least some instances.

Although early diagnosis and treatment of cancer can provide improvedoutcomes, the prior methods and apparatus of diagnosing and treatingcancer can be less than ideal. In at least some instances, patientshaving benign prostate hyperplasia (BPH) may also have prostate cancer(PCa), which may not be diagnosed as quickly as would be ideal. Also,the prior methods and apparatus for treating cancer may be less thanideally suited for combination with other treatments, for example.

Many organs such as the prostate comprise an outer wall or capsule,which comprises sensitive nerves or blood vessels. Damage to the nervesor vessels can lead to decreased functioning of the organ, and the priormethods and apparatus can provide less than ideal removal of tissue nearcapsules and walls of organs. For example, damage to nerves of theprostate capsule may lead to decreased potency, and damage to the opticnerve or vessels of the eye can lead to decreased vision in at leastsome instances.

Also, the prior methods and apparatus for sampling of tissue to collectcells may result in less ideal results in at least some instances. Itwould be desirable to provide a means for removing intact cells from apatient, so that the cells may be used for diagnostic or otherapplications. For example, stem cells are known to play an importantrole in many cancers and may be suitable test targets for the diagnosisof the cancers. Prostate stem cells, for example, have been implicatedin the development of prostate disease states, including BPH andprostate cancer. In addition, the cell lines generated from the sampledtissue may have valuable uses in cancer research and therapies such ascell-based therapies.

In light of the above, it would be helpful to provide improved methodsand apparatus for surgery and diagnosing and treating cancer. Ideallysuch methods would provide improved treatment of delicate tissuestructures such as nerves and vessels of the organ, and determine thepresence or absence of cancer and provide improved treatments withimproved outcomes.

SUMMARY

Embodiments of the present invention provide improved methods andapparatus for collecting tissue samples with intact cells. A surgicaltreatment apparatus comprises a waterjet configured to fragment tissueand provide intact cells such as stem cells with the fragmented tissue.The intact cells can be used in one or more of many ways such as forgenetic or other testing, and the intact cells can be identified as stemcells. In many embodiments, the intact cells comprise stem cells. Theharvested stem cells can be used in one or more of many ways, and can beused to generate lines of pluripotent stem cells, or to diagnose thepatient. In many embodiments, a waterjet is configured to fragmenttissue. The fragmented tissue can be collected with a filter havingpores sized smaller than the tissue fragments. In many embodimentscavitation with a waterjet is used to fragment the tissue comprising theintact stem cells. The waterjet may comprise a waterjet immersed in aliquid comprising water so as to form a plurality of shedding pulses inorder to fragment the tissue. The plurality of shedding pulses can begenerated with a frequency sufficient to fragment the tissue. Theshedding pulses can comprise vapor cavities that can coalesce intocavitation clouds that fragment the tissue.

In many embodiments, a substantially fixed flow rate system is used toharvest the fragmented tissue. A rate of fluid flow into a surgical sitemay match substantially a fluid flow out of the surgical site in orderto inhibit changes to the volume of the surgical site. A pump can beconfigured to draw fluid comprising the fragments from the site at arate similar to the flow of the waterjet. When insufflation is used, therate of draw from the site can be similar to the combined flow of thejet and insufflation, although insufflation may not be provided in atleast some embodiments. In many embodiments, a fluid reservoir iscoupled to the surgical site with a slight pressure, in order to inhibitsubstantial changes in pressure with changes in volume of the surgicalsite.

While embodiments of the present invention are specifically directed attransurethral treatment of the prostate, certain aspects of theinvention may also be used to treat and collect tissue of other organssuch as brain, heart, lungs, intestines, eyes, skin, kidney, liver,pancreas, stomach, uterus, ovaries, testicles, bladder, ear, nose,mouth, soft tissues such as bone marrow, adipose tissue, muscle,glandular and mucosal tissue, spinal and nerve tissue, cartilage, hardbiological tissues such as teeth, bone, as well as body lumens andpassages such as the sinuses, ureter, colon, esophagus, lung passages,blood vessels, and throat. The devices disclosed herein may be insertedthrough an existing body lumen, or inserted through an opening createdin body tissue.

BRIEF DESCRIPTION OF THE DRAWINGS

A better understanding of the features and advantages of the presentdisclosure will be obtained by reference to the following detaileddescription that sets forth illustrative embodiments, in which theprinciples of the disclosure are utilized, and the accompanying drawingsof which:

FIG. 1 is a schematic illustration of a device suitable for performingintraurethral prostatic tissue debulking in accordance with embodiments;

FIGS. 2A-2D illustrate use of the device of FIG. 1 in performingprostatic tissue debulking;

FIGS. 3A and 3B show a system to treat a patient in accordance withembodiments;

FIG. 4A shows pressure regulation of the surgical site with asubstantially constant pressure and variable flow, in accordance withembodiments;

FIG. 4B shows flow regulation of the surgical site with a pump providinga substantially fixed fluidic flow and a substantially constantpressure, in accordance with embodiments;

FIG. 5A shows an organ suitable for incorporation in accordance withmany embodiments;

FIG. 5B shows the prostate of FIG. 5A treated with an apparatus inaccordance with many embodiments;

FIG. 6 shows an apparatus to remove intact cells from a surgical site ofa patient, in accordance with embodiments;

FIG. 7A shows structure of the apparatus of FIG. 6.

FIG. 7B shows an ablative flame visible to the human eye, in accordancewith embodiments.

FIG. 7C shows a high speed image of the ablative flame as in FIG. 7B.

FIG. 7D shows a plurality of shedding pulses and sweeping of theablative jet to provide smooth and controlled tissue erosion at aplurality of overlapping locations in accordance with embodiments.

FIG. 7E shows maximum tissue penetration depth of cutting and flow ratethrough a nozzle in accordance with embodiments.

FIG. 7F shows selective removal of potato with a porcine blood vesselpositioned over the incision of the potato as a model for selectiveremoval of tissue.

FIG. 8 shows a filter configured to receive the fragmented tissuesamples comprising the intact cells, in accordance with embodiments;

FIGS. 9A-9D show the apparatus of FIG. 6 adapted to remove intact cellsfrom localized zones of the surgical site, in accordance withembodiments;

FIGS. 10A to 10D show images of histological sections of prostate tissueremoved from patients using the apparatus of as described herein; and

FIG. 11 shows a method of removing tissue comprising intact cells from apatient, in accordance with embodiments.

DETAILED DESCRIPTION

A better understanding of the features and advantages of the presentdisclosure will be obtained by reference to the following detaileddescription that sets forth illustrative embodiments, in which theprinciples of embodiments of the invention are utilized, and theaccompanying drawings.

Although the detailed description contains many specifics, these shouldnot be construed as limiting the scope of the invention but merely asillustrating different examples and aspects of the invention. It shouldbe appreciated that the scope of the invention includes otherembodiments not discussed in detail above. Various other modifications,changes and variations which will be apparent to those skilled in theart may be made in the arrangement, operation and details of the methodand apparatus of the present invention disclosed herein withoutdeparting from the spirit and scope of the invention as describedherein.

The embodiments as disclosed herein can be used to collect fat cells andprostate tissue, and many other types of tissue, such as tissue fromother organs, for example. The embodiments as disclosed herein are wellsuited to collect cells related to cancer, and can be used to detectbiomarkers on the surfaces of the intact harvested cells. Alternativelyor in combination, genetic testing can be performed with the cellsharvested. In many embodiments, the cells can be used to generate linesof pluripotent stem cells, for example.

The methods and apparatus as disclosed herein are well suited for usewith many other tissues in addition to the prostate. With embodimentsrelated to prostate tissue for example, the cell tissue harvestingmethods and apparatus as disclosed herein allow the surgeon to treat theprostate and harvest tissue, for example.

The embodiments disclosed herein can be combined in one or more of manyways to provide improved therapy to a patient. The disclosed embodimentscan be combined with prior methods and apparatus to provide improvedtreatment, such as combination with known methods of prostate surgeryand surgery of other tissues and organs, for example. It is to beunderstood that any one or more of the structures and steps as describedherein can be combined with any one or more additional structures andsteps of the methods and apparatus as described herein, the drawings andsupporting text provide descriptions in accordance with embodiments.Methods and apparatus of tissue removal suitable for incorporation inaccordance with embodiments as disclosed herein are described in:PCT/US2013/028441, filed on 28 Feb. 2013, entitled “AUTOMATEDIMAGE-GUIDED TISSUE RESECTION AND TREATMENT”; U.S. App. Ser. No.61/874,849, filed Sep. 6, 2013, entitled “AUTOMATED IMAGE-GUIDED TISSUERESECTION AND TREATMENT”; U.S. App. Ser. No. 61/972,730, filed Mar. 31,2014, entitled “AUTOMATED IMAGE-GUIDED TISSUE RESECTION AND TREATMENT”;U.S. App. Ser. No. 62/019,305, filed Jun. 30, 2014, entitled “AUTOMATEDIMAGE-GUIDED TISSUE RESECTION AND TREATMENT”; U.S. App. Ser. No.62/018,359, filed Jun. 27, 2014, entitled “TISSUE SAMPLING AND TREATMENTMETHODS AND APPARATUS”; U.S. App. Ser. No. 62/019,299, filed Jun. 30,2014, entitled “FLUID JET TISSUE ABLATION AND INDUCED HEMOSTATIS(AQUABLATION) METHODS AND APPARATUS”; the entire disclosures of whichhave been previously incorporated herein by reference.

Although the cell harvesting as described herein is presented in thecontext of prostate surgery, the methods and apparatus as describedherein can be used to harvest cells from any tissue of the body and anyorgan and vessel of the body such as brain, heart, lungs, intestines,eyes, skin, kidney, liver, pancreas, stomach, uterus, ovaries,testicles, bladder, ear, nose, mouth, soft tissues such as bone marrow,adipose tissue, muscle, glandular and mucosal tissue, spinal and nervetissue, cartilage, hard biological tissues such as teeth, bone, etc., aswell as body lumens and passages such as the sinuses, ureter, colon,esophagus, lung passages, blood vessels and throat.

As used herein, A and/or B encompasses A, or B, and combinationsthereof.

As used herein, the term Aquablation encompasses ablation with water orany other fluid.

As used herein, the words scope, telescope, endoscope and cytoscope areused interchangeably.

As used herein, the terms AquaBeam, flame, fluid flame, fluid cloud,entrainment region, and cavitation region are used interchangeably.

As used herein a processor encompasses one or more processors, forexample a single processor, or a plurality of processors of adistributed processing system for example. A controller or processor asdescribed herein generally comprises a tangible medium to storeinstructions to implement a steps of a process, and the processor maycomprise one or more of a central processing unit, programmable arraylogic, gate array logic, or a field programmable gate array, forexample.

As used herein like characters and numerals identify like elements.

As used herein, a real time image shown on a display encompasses animage shown within a few seconds of the event shown. For example, realtime imaging of a tissue structure encompasses providing the real timeimage on a display within about ten seconds of the image being acquired.

As used herein, the terms distal and proximal refer to locationsreferenced from the apparatus, and can be opposite of anatomicalreferences. For example a distal location of a probe may correspond to aproximal location of an elongate member of the patient, and a proximallocation of the probe may correspond to a distal location of theelongate member of the patient.

Automated robotic control—where movement of the waterjet is motorizedand under computer control with preselected routines—allows accurate andfinely detailed resections not possible with manual control. Advantagesinclude reduced time required for procedures, fewer complications,improved outcomes and less training time needed for surgeons. Many ofthese improvements arise from reducing or eliminating the need formanual dexterity of the treating physician. Automatic control furtherallows the cutting power of the nozzle to be increased to levels notachievable with full manual control. The system may be manuallycontrolled during less critical portions of the procedure, e.g. duringinitial selection of an area to operate on and for touch-ups in cuttingand cautery. Even during these less critical phases of the protocols,the increased precision and smoothness provided by the automated controlcan provide reduction and filtering of hand jitter. Another significantadvantage is that automation allows for pretesting or “dry runs” of aprocedure. When a cutting routine is selected, the limits of area can beselected using a joystick or other control element to position the laserduring a mock the procedure without cutting. Changes can be made beforecutting commences, so that errors can be corrected before beginning theactual procedure.

INCORPORATION BY REFERENCE

The subject matter of FIGS. 1 to 2D and the corresponding text have beenincorporated by reference as described in: U.S. application Ser. No.12/700,568, filed Feb. 4, 2010, entitled “MULTI FLUID TISSUE RESECTIONMETHODS AND DEVICES”, published as US 20110184391; and PCT ApplicationPCT/US2011/023781 filed on Feb. 4, 2011, published as WO2011097505 onNov. 8, 2011, entitled “MULTI FLUID TISSUE RESECTION METHODS ANDDEVICES”; the full disclosures of which have been previouslyincorporated herein by reference.

Referring to FIG. 1, an exemplary prostatic tissue debulking device 10constructed in accordance with the principles of the present inventioncomprises a catheter assembly generally including a shaft 12 having adistal end 14 and a proximal end 16. The shaft 12 will typically be apolymeric extrusion including one, two, three, four, or more axiallumens extending from a hub 18 at the proximal end 16 to locations nearthe distal end 14. The shaft 12 will generally have a length in therange from 15 cm to 25 cm and a diameter in the range from 1 mm to 10mm, usually from 2 mm to 6 mm. The shaft will have sufficient columnstrength so that it may be introduced upwardly through the male urethra,as described in more detail below.

The shaft will include an energy source positioned in the energydelivery region 20, where the energy source can be any one of a numberof specific components as discussed in more detail below. Distal to theenergy delivery region, an inflatable anchoring balloon 24 will bepositioned at or very close to the distal end 14 of the shaft. Theballoon will be connected through one of the axial lumens to a ballooninflation source 26 connected through the hub 18. In addition to theenergy source 22 and the balloon inflation source 26, the hub willoptionally further include connections for an infusion/flushing source28, an aspiration (a vacuum) source 30, and/or an insufflation(pressurized C02 or other gas) source 32. In the exemplary embodiment,the infusion or flushing source 28 can be connected through an axiallumen (not shown) to one or more delivery ports 34 proximal to theballoon anchor 24 and distal to the energy delivery region 20. Theaspiration source 30 can be connected to a second port or opening 36,usually positioned proximally of the energy delivery region 20, whilethe insufflation source 32 can be connected to an additional port 38,also usually located proximal of the energy delivery region. It will beappreciated that the locations of the ports 34, 36, and 38 are notcritical, although certain positions may result in particular advantagesdescribed herein, and that the lumens and delivery means could beprovided by additional catheters, tubes, and the like, for exampleincluding coaxial sleeves, sheathes, and the like which could bepositioned over the shaft 12.

While the present embodiments are described with reference to the humanprostate, it is understood that they may be used to treat mammalprostates in general. Referring now to FIGS. 2A-2D, the prostatic tissuedebulking device 10 is introduced through the male urethra U to a regionwithin the prostate P which is located immediately distal to the bladderB. The anatomy is shown in FIG. 2A. Once the catheter 10 has beenpositioned so that the anchoring balloon 24 is located just distal ofthe bladder neck BN (FIG. 2B) the balloon can be inflated, preferably tooccupy substantially the entire interior of the bladder, as shown inFIG. 2C. Once the anchoring balloon 24 is inflated, the position of theprostatic tissue debulking device 10 will be fixed and stabilized withinthe urethra U so that the energy delivery region 20 is positioned withinthe prostate P. It will be appreciated that proper positioning of theenergy delivery region 20 depends only on the inflation of the anchoringballoon 24 within the bladder. As the prostate is located immediatelyproximal to the bladder neck BN, by spacing the distal end of the energydelivery region very close to the proximal end of the balloon, typicallywithin the range from 0 mm to 5 mm, preferably from 1 mm to 3 mm, thedelivery region can be properly located. After the anchoring balloon 24has been inflated, energy can be delivered into the prostate fordebulking, as shown by the arrows in FIG. 2C. Once the energy has beendelivered for a time and over a desired surface region, the energyregion can be stopped and the prostate will be debulked to relievepressure on the urethra, as shown in FIG. 2D. At that time, a flushingfluid may be delivered through port 34 and aspirated into port 36, asshown in FIG. 2D. Optionally, after the treatment, the area could becauterized using a cauterizing balloon and/or stent which could beplaced using a modified or separate catheter device.

FIGS. 3A and 3B show a system to treat a patient in accordance withembodiments. The system 400 comprises a treatment probe 450 and mayoptionally comprise an imaging probe 460. The treatment probe 450 iscoupled to a console 420 and a linkage 430. The imaging probe 460 iscoupled to an imaging console 490. The patient treatment probe 450 andthe imaging probe 460 can be coupled to a common base 440. The patientis supported with the patient support 449. The treatment probe 450 iscoupled to the base 440 with an arm 442. The imaging probe 460 iscoupled to the base 440 with an arm 444.

The patient is placed on the patient support 449, such that thetreatment probe 450 and ultrasound probe 460 can be inserted into thepatient. The patient can be placed in one or more of many positions suchas prone, supine, upright, or inclined, for example. In manyembodiments, the patient is placed in a lithotomy position, and stirrupsmay be used, for example. In many embodiments, the treatment probe 450is inserted into the patient in a first direction on a first side of thepatient, and the imaging probe is inserted into to the patient in asecond direction on a second side of the patient. For example, thetreatment probe can be inserted from an anterior side of the patientinto a urethra of the patient, and the imaging probe can be insertedtrans-rectally from a posterior side of the patient into the intestineof the patient. The treatment probe and imaging probe can be placed inthe patient with one or more of urethral tissue, urethral wall tissue,prostate tissue, intestinal tissue, or intestinal wall tissue extendingtherebetween.

The treatment probe 450 and the imaging probe 460 can be inserted intothe patient in one or more of many ways. During insertion, each arm maycomprise a substantially unlocked configuration such the probe can bedesirably rotated and translated in order to insert the probe into tothe patient. When a probe has been inserted to a desired location, thearm can be locked. In the locked configuration, the probes can beoriented in relation to each other in one or more of many ways, such asparallel, skew, horizontal, oblique, or non-parallel, for example. Itcan be helpful to determine the orientation of the probes with anglesensors as described herein, in order to map the image date of theimaging probe to treatment probe coordinate references. Having thetissue image data mapped to treatment probe coordinate reference spacecan allow accurate targeting and treatment of tissue identified fortreatment by an operator such as the physician.

In many embodiments, the treatment probe 450 is coupled to the imagingprobe 460, in order to align the treatment with probe 450 based onimages from imaging probe 460. The coupling can be achieved with thecommon base 440 as shown. Alternatively or in combination, the treatmentprobe and/or the imaging probe may comprise magnets to hold the probesin alignment through tissue of the patient. In many embodiments, the arm442 is a movable and lockable arm such that the treatment probe 450 canbe positioned in a desired location in a patient. When the probe 450 hasbeen positioned in the desired location of the patient, the arm 442 canbe locked with an arm lock 427. The imaging probe can be coupled to base440 with arm 444, can be used to adjust the alignment of the probe whenthe treatment probe is locked in position. The arm 444 may comprise alockable and movable probe under control of the imaging system or of theconsole and of the user interface, for example. The movable arm 444 maybe micro-actuable so that the imaging probe 440 can be adjusted withsmall movements, for example a millimeter or so in relation to thetreatment probe 450.

In many embodiments the treatment probe 450 and the imaging probe 460are coupled to angle sensors so that the treatment can be controlledbased on the alignment of the imaging probe 460 and the treatment probe450. An angle sensor 495 is coupled to the treatment probe 450 with asupport 438. An angle sensor 497 is coupled to the imaging probe 460.The angle sensors may comprise one or more of many types of anglesensors. For example, the angle sensors may comprise goniometers,accelerometers and combinations thereof. In many embodiments, anglesensor 495 comprises a 3-dimensional accelerometer to determine anorientation of the treatment probe 450 in three dimensions. In manyembodiments, the angle sensor 497 comprises a 3-dimensionalaccelerometer to determine an orientation of the imaging probe 460 inthree dimensions. Alternatively or in combination, the angle sensor 495may comprise a goniometer to determine an angle of treatment probe 450along an elongate axis of the treatment probe. Angle sensor 497 maycomprise a goniometer to determine an angle of the imaging probe 460along an elongate axis of the imaging probe 460. The angle sensor 495 iscoupled to a controller 424. The angle sensor 497 of the imaging probeis coupled to a processor 492 of the imaging system 490. Alternatively,the angle sensor 497 can be coupled to the controller 424 and also incombination.

The console 420 comprises a display 425 coupled to a processor system incomponents that are used to control treatment probe 450. The console 420comprises a processor 423 having a memory 421. Communication circuitry422 is coupled to processor 423 and controller 422. Communicationcircuitry 422 is coupled to the imaging system 490. The console 420comprises components of an endoscope 35 that is coupled to anchor 24.Infusion flashing control 28 is coupled to probe 450 to control infusionand flushing. Aspiration control 30 is coupled to probe 450 to controlaspiration. Endoscope 426 can comprise components of console 420 and anendoscope insertable with probe 450 to treat the patient. Arm lock 427of console 420 is coupled to arm 422 to lock the arm 422 or to allow thearm 422 to be freely movable to insert probe 450 into the patient.

The console 420 may comprise a pump 419 coupled to the carrier andnozzle as described herein.

The processor, controller and control electronics and circuitry caninclude one or more of many suitable components, such as one or moreprocessor, one or more field-programmable gate array (FPGA), and one ormore memory storage devices. In many embodiments, the controlelectronics controls the control panel of the graphic user interface(hereinafter “GUI”) to provide for pre-procedure planning according touser specified treatment parameters as well as to provide user controlover the surgery procedure.

The treatment probe 450 comprises an anchor 24. The anchor 24 anchorsthe distal end of the probe 450 while energy is delivered to energydelivery region 20 with the probe 450. The probe 450 may comprise anozzle 200 as described herein. The probe 450 is coupled to the arm 422with a linkage 430.

The linkage 430 comprises components to move energy delivery region 20to a desired target location of the patient, for example, based onimages of the patient. The linkage 430 comprises a first portion 432 anda second portion 434 and a third portion 436. The first portion 432comprises a substantially fixed anchoring portion. The substantiallyfixed anchoring portion 432 is fixed to support 438. Support 438 maycomprise a reference frame of linkage 430. Support 438 may comprise arigid chassis or frame or housing to rigidly and stiffly couple arm 442to treatment probe 450. The first portion 432 remains substantiallyfixed, while the second portion 434 and third portion 436 move to directenergy from the probe 450 to the patient. The first portion 432 is fixedto the substantially constant distance 437 to the anchor 24. Thesubstantially fixed distance 437 between the anchor 24 and the fixedfirst portion 432 of the linkage allows the treatment to be accuratelyplaced. The first portion 424 may comprise the linear actuator toaccurately position the high pressure nozzle in treatment region 20 at adesired axial position along an elongate axis of probe 450.

The elongate axis of probe 450 generally extends between a proximalportion of probe 450 near linkage 430 to a distal end having anchor 24attached thereto. The third portion 436 controls a rotation angle aroundthe elongate axis. During treatment of the patient, a distance 439between the treatment region 20 and the fixed portion of the linkagevaries with reference to anchor 24. The distance 439 adjusts in responseto computer control to set a target location along the elongate axis ofthe treatment probe referenced to anchor 24. The first portion of thelinkage remains fixed, while the second portion 434 adjusts the positionof the treatment region along the axis. The third portion of the linkage436 adjusts the angle around the axis in response to controller 424 suchthat the distance along the axis at an angle of the treatment can becontrolled very accurately with reference to anchor 24. The probe 450may comprise a stiff member such as a spine extending between support438 and anchor 24 such that the distance from linkage 430 to anchor 24remains substantially constant during the treatment. The treatment probe450 is coupled to treatment components as described herein to allowtreatment with one or more forms of energy such as mechanical energyfrom a jet, electrical energy from electrodes or optical energy from alight source such as a laser source. The light source may compriseinfrared, visible light or ultraviolet light. The energy delivery region20 can be moved under control of linkage 430 such as to deliver anintended form of energy to a target tissue of the patient.

The imaging system 490 comprises a memory 493, communication circuitry494 and processor 492. The processor 492 in corresponding circuitry iscoupled to the imaging probe 460. An arm controller 491 is coupled toarm 444 to precisely position imaging probe 460.

FIG. 4A shows pressure regulation of the surgical site with asubstantially constant pressure and variable flow. The saline bag isplaced at a height to provide substantially constant pressureregulation. The bag of saline can be placed at a height corresponding toabout 50 to 100 mm of Mercury (hereinafter “mmHg”). The saline bag iscoupled to the irrigation port as described herein. A collection bag iscoupled to one or more of the irrigation port, the aspiration port, orthe suction port as described herein. The collection bag collects tissueremoved with the waterjet ablation probe 450 as described herein.

FIG. 4B shows flow fluidic regulation of the surgical site with a pumpproviding a substantially fixed fluidic flow. A pump removes fluid fromthe surgical site at a substantially fixed flow rate. The pump maycomprise a peristaltic pump, for example. The pump is configured toremove fluid at substantially the same rate or greater than theAquablation saline flow rate, in order to inhibit pressure build up atthe surgical site. The peristaltic pump can be coupled to the aspirationport of the manifold comprising tissue removal port 456C as describedherein, for example. Providing the pump having the flow rate that is atleast the flow rate of the tissue ablation jet provides improve suctionas ablated tissue that might otherwise block the tissue removal openingsand channel can be subjected to greater amounts of pressure when thepump maintains the substantially fixed flow rate in order to remove thematerial that would otherwise block the channel.

The irrigation flow from the saline bag may remain open in order toprovide at least two functions: 1) maintain pressure based on the heightof the saline bag; and 2) provide a safety check valve in case theperistaltic pump is not functioning correctly as visually a person wouldsee flow entering the bag as a pink color.

In alternate embodiments, the flow of the pump comprises a variable ratein order to provide a substantially constant pressure within the patientnear the surgical site. The active sensing of pressure of the treatedorgan and variable flow rate of the pump may comprise a closed looppressure regulation system. The pump can be coupled to a sensor such asa pressure sensor, and the flow rate varied to maintain substantiallyconstant pressure. The pressure sensor can be located in one or more ofmany places such as on the treatment probe, within the aspirationchannel of the probe, in a recess of an outer surface the probe, on aninner surface of the probe coupled to the surgical site, or near theinlet to the pump on the console for example.

FIG. 5A shows an organ suitable for incorporation in accordance withembodiments. The organ may comprise one or more of many organs asdescribed herein, for example, the prostate. In many embodiments theorgan comprises a capsule and tissue contained within the capsule andcapsular vessels and nerves located on an exterior of the capsule, forexample. In many embodiments the organ comprises a prostate. Theprostate may comprise hyperplasia such as benign prostate hyperplasia orcancer and combinations thereof, for example. In many embodiments thehyperplasic tissue may comprise tissue located within the patient inwhich the cancer may not have been detected. In many embodimentscapsular vessels and nerves extend along an exterior surface of theprostate. In many embodiments the hyperplasic tissue can be locatedsuperiorly on the prostate. In the many embodiments the hyperplasictissue may comprise tissue of unknown specificity with respect towhether the tissue comprises cancerous tissue or benign tissue.

FIG. 5B shows the prostate of FIG. 5A treated with an apparatus inaccordance with embodiments. In many embodiments the tissue of theprostate is removed in accordance with a tissue removal profile. Thetissue removal profile may comprise of predetermined tissue removalprofile based on image-guided tissue removal as described herein, forexample. Alternatively the tissue removal profile may comprise ofremoval profile of tissue removed with a handheld tissue removalapparatus. In many embodiments the tissue of the organ, such as theprostate, is removed to within the capsule in order to decrease thedistance from the tissue removable profile to the exterior of thecapsule, for example.

In many embodiments a tissue treatment apparatus, such as a catheterhaving an expandable support, is placed within the organ in order toengage the remaining tissue that defines the removal profile and thecapsule with an expandable support.

In many embodiments the tissue within the organ is removed such that thecapsule of the organ, such as the prostate, remains intact which has theadvantage of retaining the integrity of the capsule or vessel's nerveswhich may extend around an exterior surface of the capsule. In manyembodiments this removal of the capsular tissue is inhibited in order toretain the integrity of the capsule and the corresponding tissuestructures such as capsular vessels and/or nerves. The tissue removalprofile may define a cavity corresponding to the removed tissue of theorgan such as the prostate. In many embodiments a portion of the tissuenear the capsule may comprise tissue, such as cancerous tissue or tissueidentified as having a probability of being cancerous tissue, such ashyperplasic tissue in the superior portion or other portion of theorgan.

FIG. 6 shows an apparatus 600 to remove intact cells from a surgicalsite of a patient. The apparatus 600 may comprise one or more componentsof system 10 or system 400 as described herein, for example. Theapparatus comprises a probe 650 that may be inserted to the surgicalsite. The probe comprises a nozzle 610 configured to provide a fluidstream to the surgical site to fragment tissue, and a port 630configured to receive the tissue from the surgical site. The port iscoupled to one or more filters 636 configured to receive the tissuecomprising the intact cells from the surgical site. The one or morefilters may be further coupled to a collection apparatus 638 that housesthe one or more filters. Optionally, the collection apparatus may becoupled to an external vacuum pump 640 configured to provide additionalnegative pressure to help assist in the collection of the fragmentedtissue.

The apparatus may further comprise a first channel 612 extending from afluid source 614 to the nozzle to generate the fluid stream, and secondchannel 632 extending from the port toward the filter to transport thefragmented tissue away from the surgical site. The fluid source maycomprise a first pump 616 connected to the first channel, configured todrive the fluid stream from the fluid source to the nozzle. The secondchannel may be further coupled to a second pump 634, configured totransport the fragmented tissue from the port to the filter.

In some embodiments, the flow rate of the first pump and the flow rateof the second pump are configured to be substantially similar, such thatthe tissue fragments and fluid are removed at a rate similar to the rateof the fluid injected into the surgical site with the fluid stream.

The nozzle and the port may be configured to provide a closed surgicalsite 650 within the patient, such that a constant volume of fluid ismaintained within the surgical site. The apparatus may further comprisea fluid reservoir 660 and a channel 662 extending between the fluidreservoir and the surgical site. The fluid reservoir can help toaccommodate any differences between the flow rate of the first pump andthe flow rate of the second pump, so that the volume of the closedsurgical site remains substantially constant and pressure build-up atthe surgical site is inhibited. The fluid reservoir may provide a safetycheck valve in case one or more of the first or second pump is notfunctioning correctly, for example as when a tissue fragment is blockingthe port.

Work in relation to embodiments suggests that the substantially fixedpressure of the closed surgical site can treat the intact cells gentlyand allow the fragment tissue to flow to the collection devicecomprising the filter.

FIG. 7A shows an exemplary probe in accordance with embodiments of theapparatus as described herein such as apparatus 600. In the exemplaryembodiments of FIG. 7A, the apparatus may be used to remove intact cellsfrom a prostate P of a patient. The apparatus comprises a prostatictissue debulking device 10 as described herein, wherein the devicecomprises a probe 450 that may be inserted into the male urethra U to asurgical region within the prostate located immediately distal to thebladder B of the patient. The probe comprises a nozzle 610 to deliver afluid stream 618 to the surgical region, and thereby remove a pluralityof tissue fragments 642 from the prostate. The probe also comprises oneor more ports 630 to receive the slurry 644 from the surgical site,where the slurry comprises fluid from the fluid stream and tissuefragments removed from the prostate. The fluid stream may be deliveredto the nozzle through a first channel 612, which is connected to a fluidsource comprising a first pump. The slurry may be transported from thesurgical site through a second channel 632, to a filter configured toreceive the slurry.

The nozzle may comprise an inner restricted diameter corresponding to adiameter of the fluid stream released from the nozzle. The innerrestricted diameter of the nozzle may range from about 25 um to about500 um, preferably within a range from about 100 um to about 200 um,more preferably from 120 um to 150 um.

The fluid stream may comprise one or more of a liquid or a gas. A liquidfluid stream may comprise one or more of water or saline, for example. Aliquid fluid stream may be configured to exit the nozzle in the form aliquid ablation jet 620, causing cavitations in the prostate tissue anddissociating the tissue into a plurality of fragments.

FIG. 7B shows an ablative flame visible to the human eye, in accordancewith embodiments.

FIG. 7C shows a high speed image of the ablative flame as in FIG. 7B.The image was taken at a speed of about 1/400 of a second.

The data of FIGS. 7B and 7C show that the ablative flame comprises aplurality of white clouds generated with the ablative stream whenreleased from the nozzle. Work in relation to embodiments has shown thatthe cavitating cloud can shed from the jet at a characteristic sheddingfrequency. A length 992 of each cloud is related to the sheddingfrequency and the velocity of the cloud. The relatively cool ablativeflame of the jet comprises a length 990 corresponding to the cuttinglength of the jet which can be adjusted to cut tissue to controlleddepth as described herein. In many embodiments, nozzle of the jet isplaced at least about a quarter of the length 992 of a shed cloud in annon-cutting configuration as shown in FIG. 7C, in order to allow theshedding cloud to substantially form prior to the cloud striking tissue.This divergence of the shed cloud to a larger cross sectional size canalso provide improved tissue removal as the cloud can be distributed toa larger region of tissue and provide improved overlap among the pulsesof the jet.

In addition to the impact pressure of the jet, the highly turbulent andaggressive region corresponding to the white cloud of the imagecontributes substantially to the ablation of tissue as described herein.The white cloud comprises a plurality of cavitation regions. Whenpressurized water is injected into water, small cavitations aregenerated in areas of low pressure in the shear layer, near the nozzleexit. The small cavitations may comprise cavitation vortices. Thecavitation vortices merge with one another, forming large discretecavitation structures that appear in the high speed images as cavitationclouds. These cavitation clouds provide effective ablation wheninteracting with tissue. Without being bound by any particular theory,it is believed that the cavitation clouds striking tissue causesubstantial erosion of tissue related to the cavitations in combinationof the high velocity fluid that defines the cavitations striking tissue.

The nozzle and pressure as described herein can be configured to providethe pulsatile clouds, for example with control of the angle of thenozzle, by a person of ordinary skill on the art based on the teachingsprovided herein. In many embodiments, the nozzle of the fluid deliveryelement comprises a cavitating jet in order to improve ablation oftissue.

The fluid delivery element nozzle and pressure can be arranged toprovide a shedding frequency suitable for removal of tissue and can belocated on the probe to provide improved tissue resection.

In many embodiments, the “white cloud” of “flame” comprises an“entrainment” region where surrounding water is drawn in or “entrained”into the jet. Work in relation to embodiments suggests that theentrainment of fluid can be related to the shedding frequency.

The shedding frequency and size of the cloud shed from the jet can beused to provide tissue ablation in accordance with embodiments. Theshedding frequency can be combined with the angular sweep rate of theprobe around the longitudinal axis to provide overlap of the locationswhere each cloud interacts with the tissue.

FIG. 7D shows a plurality of shedding pulses 995 and sweeping of theablative jet to provide smooth and controlled tissue erosion at aplurality of overlapping locations 997 in accordance with embodiments.This shedding frequency can be substantially faster than the pumpfrequency, when a pump is used, such that a plurality of shedding cloudsare provided for each pulse of the pulsatile pump. The sweep rate of theprobe can be related to shedding frequency to provide improved tissueremoval, for example with the shedding clouds configured to provideoverlapping pulses.

In many embodiments, the system comprises a pump having a frequency lessthan a frequency of the shedding pulses, in order to provide a pluralityof shedding pulses for each pulse of the pump. The pump can have a pulserate of at least about 50 Hz, for example within a range of about 50 Hzto about 200 Hz, and the shedding pulses comprise a frequency of atleast about 500 Hz, for example within a range from about 1 kHz to about10 kHz.

Although pulses of a pump are illustrated, similar scanning of pulsedclouds can be provided with a continuous flow pump.

While the nozzle can be configured in one or more of many ways, in manyembodiments the nozzle comprises a Strouhal number (hereinafter “St”)within a range from about 0.02 to about 0.3, for example within a rangefrom about 0.10 to about 0.25, and in many embodiments within a rangefrom about 0.14 to about 0.2.

In many embodiments, the Strouhal number is defined by:St=(Fshed)*(W)/U

where Fshed is the shedding frequency, W is the width of the cavitatingjet, and U is the velocity of the jet at the exit. A person of ordinaryskill in the art can modify nozzles as described herein in order toobtain shedding frequencies suitable for combination in accordance withembodiments described herein, and experiments can be conducted todetermine the cloud lengths and shedding frequencies suitable for tissueremoval.

The nozzle configurations providing plurality of shedding clouds aresuitable for use with one or more of the probes as described herein. Thenozzle may be arranged with the port in order to immerse the liquid jetin a liquid in order to generate a plurality of shedding pulses with thejet immersed in the liquid.

The flow rate of the fluid stream may range from about 10 ml/min toabout 500 ml/min, preferably within the range from about 50 ml/min toabout 250 ml/min. A fluid ablation jet exiting the nozzle may have alongitudinal velocity ranging from about 0.01 mm/sec to about 50 mm/sec,preferably within the range from about 0.1 mm/sec to about 5 mm/sec.

The probe may be configured such that the fluid ablation jet rotatesduring the tissue removal procedure, such that tissue samples can becollected from various locations within the surgical site. The rotationof the fluid ablation jet during the course of tissue removal may be inthe range from 0 to 360 degrees, preferably within the range of about 30degrees to about 300 degrees. The angular velocity of the jet around thelongitudinal axis of the probe may range from about 10 deg/sec to about2000 deg/sec, preferably within the range of about 180 deg/sec to about900 deg/sec. The longitudinal length of the profile of the tissueremoval procedure may range from about 0.1 mm to about 300 mm,preferably within the range of about 1 mm to about 70 mm.

Experimental

FIG. 7E shows maximum tissue penetration depth of cutting and flow ratethrough a nozzle in accordance with embodiments. The maximum penetrationdepth corresponds substantially to the length of the cavitation bubblesof the jet comprising the “cold” aquablation flame. The maximum tissuepenetration depth of ablation corresponds directly to the flow rate andin many embodiments is linearly related to the flow rate.

The inset of FIG. 7E shows cut potato as a model of prostate BPH, inaccordance with embodiments. The maximum penetration depth of potatocorresponds closely to the maximum cut depth of BPH. The potato is showncut with 10 different flow settings corresponding to rates within arange from about 50 ml/min to about 250 ml/min with a nozzle androtating probe as described herein. The maximum penetration depth rangesfrom about 4 mm at 50 ml/min to about 20 mm at about 250 ml/min.

In many embodiments, the cavitation cloud growth and length comprises afunction of flow rate, which is proportional to the injection pressureand vice versa, for an appropriately configured nozzle as describedherein. As the pressure increases, the maximum erosive radius appears toincrease linearly, which is shown as the maximum penetration depth ofFIG. 7E.

High velocity cavitating jets can be created by using an known highpressure pump to force the water through a nozzle in either a continuousor pulsatile flow. Despite the flow type produced by a pump, thecavitation phenomenon will be pulsatile due to the unsteady nature ofvapor cavities and the cavity formation will be pulsatile even in acontinuous flow jet as described herein. Without being bound to aparticular theory, it is believed that both pulsatile and continuousflow waterjets will result in equivalent amounts of material erosionover a given amount of time. In many embodiments, nozzle geometry isconfigured to provide the flow dynamics and cavitation process asdescribed herein. In many embodiments, the nozzle is configured toinhibit tight constriction at the waterj et exit, which can be relatedcavitation can occur inside the nozzle itself. In many embodiments, thesharp corners cause the water to separate from the wall and convergetowards the nozzle centerline, further constricting the waterj etpathway while simultaneously reducing frictional effects caused by thenozzle wall. This results in an increased velocity along with thecorresponding pressure drop and the vapor cavities formation. Vaporcavity formation will impact the overall flow dynamics as their eventualcollapse results in turbulence and can affect erosion depth. A person ofordinary skill in the art can conduct experiments to determineappropriate nozzle geometry and flow rate to provide tissue removal asdescribed herein without undue experimentation.

Aquablation

Submerged waterjet cutting as described herein has the capability totake advantage of the cavitation phenomenon to treat patients withBenign Prostatic Hyperplasia (BPH). The jet removes the excess softtissue growth seen in BPH through the pressure pulses and microjetscaused by collapsed vapor cavities. The waterjet direction can bemanipulated by changing the location and orientation of the devicesnozzle, either by translating the nozzle along the anterior-posteriordirection or by rotating the nozzle up to 180 degrees, for example.

As vapor cavity formation and its erosive strength is a function of bothinjection pressure and the flow dynamics, the depth of material can becontrolled by configuring the pressure as well as nozzle geometry. Agreater injection pressure will result in a faster exit velocity. Asdiscussed herein, the nozzle geometry can further increase the velocitydepending on the constriction and will affect the degree of pressuredrop as the waterj et exits through the Venturi effect. These factorscan result in longer distances the cavitation clouds can grow to andtravel before collapsing and releasing pressure pulses and microjets.The nozzle geometry and pressure settings of the Aquablation system havebeen optimized to give the user precise control and ensure thecavitating jet removes only the desired benign tissue growth.

The images provided herein show the how tissue erosion depth is afunction of pressure, in accordance with embodiments. The images showthe smaller cavitation cloud length and corresponding tissue resectiondepth for a lower injection pressure as compared with other images.

In many embodiments, Aquablation as described herein is capable ofremoving the excess tissue growth, e.g. BPH, with inhibited removal anddamage of arteries and veins. The pressure pulses and microjets causedby cavitation exceed the threshold energy required to erode the softtissue growth, and may cause minimal damage to other structures likevessels which have a much higher threshold energy. Repeated andconcentrated pressure pulses and microjets may cause fatigue stress onthe vasculature and result in bleeding, but the Aquablation systemalgorithm and treatment instructions as described herein are configureddesigned to inhibit such damage.

In many embodiments, generation of harmful emboli are inhibited. Vaporcavity formation may benefit from a minute nucleus of air alreadypresent in the blood stream, for example. Cavitation can result in thegrowth of the nucleus without any additional air being introduced intothe system. Furthermore, the cavity will collapse once the local jetpressure exceeds the vapor pressure, such that the air pockets mayreduce back to their original nucleus size. In many embodiments, embolusformation is inhibited as cavitation depends on and can be limited tomicro amounts of air native to the saline solution surrounding theurethra, and the vapor cavities quickly dissipate as the jet pressurebegins to rise.

Aquablation as described herein takes advantage of this phenomenon. Thenaturally self-limiting erosive radius and unique ability to preciselyablate tissue with a low damage threshold energy while minimizing damageto nearby structures with a more dense cellular structure, such asarteries, make Aquablation as described herein a useful surgical toolfor treating BPH. Coupled with the nearly isothermal property ofcavitation as described herein, which can mitigate collateral damage andprovide improved healing and an improved safety profile.

FIG. 7F shows selective removal of potato with a porcine blood vesselpositioned over the incision of the potato as a model for selectiveremoval of tissue. The porcine blood vessel was placed on the potatoprior to the incision, such that the porcine blood vessel was exposed tothe water jet with cavitation in order to remove the potato. Aquablationresected the soft potato tissue model, which is a close proxy for thebenign tissue growth seen in BPH, without causing severe damage to theporcine vessel.

While the embodiments of FIG. 7A describes an apparatus to remove cellsfrom prostate tissue, one of skill in the art will appreciate that theapparatus may be adapted to remove cells of other tissues of an organ.

FIG. 8 shows a filter 636 configured to receive the fragmented tissue642 samples comprising the intact cells, in accordance with embodiments.The filter is coupled to the surgical site through the second channel632. The second channel is also coupled to a second pump 634 configuredto transport the fragmented tissue from the port to the filter. Thesecond pump may comprise a peristaltic pump 635 that moves the tissuesamples by positive displacement, wherein the peristaltic pump may beconfigured to pump at a rate substantially similar to the rate of firstpump driving the fluid stream, for example similar to within about 10%,for example 5% or less. Alternately, the second pump may comprise avacuum pump that moves the tissue samples by negative pressure, whereinthe vacuum pump may be configured with a trap to main the sterility ofthe samples and of the pump mechanism.

The filter may comprise a plurality of pores 637 having a plurality ofpore sizes. The pore sizes may be dimensioned to be larger than thedimensions of the intact cells 643 of the tissue being removed, so thatthe tissue fragments comprising the cells may be collected with thefilter.

The filter may be further coupled to a collection apparatus 638 thathouses the filter, wherein the filter is removable and replaceable.Optionally, the collection apparatus may be coupled to an externalvacuum pump 640 configured to provide additional negative pressure tohelp assist in the collection of the fragmented tissue. Once tissuesamples have been collected in the filter, the filter may be removedfrom the collection apparatus and sent for the harvesting of the intactcells disposed in the tissues, or for other procedures as describedherein.

The removed tissue comprising intact cells may be analyzed fordiagnostic purposes, such as for the diagnosis of cancer. For example,removed prostate tissue may be analyzed for the diagnosis of prostatecancer (PCa) or benign prostate hyperplasia (BPH). Tissue fragments maybe analyzed via histology or immunohistochemistry for the presence ofcancer. Further, intact cells within the tissue fragments may beharvested and used for cellular analysis to detect cancer. Studies haveshown that prostate stem cells display different biomarkers depending onwhether they are normal, BPH, or PCa stem cells (Prajapati et al.,Biomed Res Int 2013; 2013:107954). Cells may be separated from thetissue fragments using methods well known in the art, such collagenasedigestion of tissue followed by repeated centrifugation to release andseparate cells. Separated cells may be expanded in vitro, then analyzedfor biomarker expression via immunocytochemistry or flow cytometry, asis well known in the art. One or more of the following biomarkers forprostate stem cells may be analyzed: CD44, p63, Sca-1, CD133, p27Kip1,CD117, Trop2, CD49f, AR, CK5, 8, PSCA. Prostate stem cells may beidentified as normal, for example when they display the profilep63(+)AR(−)CK5(+)8(−), or they may be identified as BPH, for examplewhen they display the profile p63(+)AR(+)CK5(+)8(−)PSCA^(hi), or theymay be identified as prostate cancer, for example when they display theprofile p63(−)ARHCK5(−)8(−)PSCA^(hi). Identification of the cells asnormal, BPH, or PCa stem cells can help diagnose BPH or PCa in thetissue sample, and help decide the subsequent course of treatment forthe patient.

The removed tissue comprising intact cells may also be processed togenerate cell lines for use in research and therapeutics. For example,prostate stem cells may be harvested from resected prostate tissue togenerate pluripotent stem cell lines for potential use in cancerresearch and cell-based therapeutics. Cells may be harvested from thetissue fragments and expanded in vitro, as described herein. Cellsdisplaying cell-surface markers for stem cells, such as CD44, integrinα2β1, CD133, and CK6a, may be sorted via immunomagnetic sorting orfluorescence-activated cell sorting (FACS), as is well-known in the art.Sorted cells may be expanded in vitro and subsequently verified fortheir expression of target biomarkers, such as via reverse-transcriptasepolymerase chain reaction (RT-PCR) and gel electrophoresis, westernblotting, immunocytochemistry, or flow cytometry. The sorted cells maybe further evaluated for their ability to differentiate in vitro or invivo. Some studies have shown that pluripotent stem cell lines may bederived from resected human prostate tissue, with potential uses instudies of prostatic disorders as well as in regenerative medicine(Prajapati et al., J Stem Cell Res Ther 2014; 4:1).

An apparatus for the removal of tissue comprising intact cells asdescribed herein may be further configured to enable the removal oftissue fragments from localized zones within the surgical site.

FIGS. 9A-9D show the apparatus 600 adapted to remove intact cells fromlocalized zones 652 of the surgical site, in accordance withembodiments. In the exemplary embodiment of FIGS. 9A-9D, the apparatusis used to remove intact cells from a prostate P of a patient. The probe450 of the apparatus may be threaded through the urethra U to reach thebladder B. As shown in FIGS. 9A and 9B, the probe may be retractedproximally in the direction indicated by arrow 201 to remove tissue fromthe base of the prostate P to the apex of the prostate such as with aliquid jet 620. As tissue is removed, the resected tissue may besuctioned through the ports 630 into a channel 632 that transport thetissue to filters.

In order to harvest tissue and cells from localized zones, the prostateP may be divided into cutting zones Z1, Z2, Z3, Z4, Z5, Z6, and Z7. Thezones Z1, Z2, Z3, Z4, Z5, Z6, and Z7 may be sagittal zones and the probe(and the liquid jet) may be fully rotated as the probe is retracted. Thezones Z1, Z2, Z3, Z4, Z5, Z6, and Z7 may be transverse zones and theprobe (and the liquid jet) may be partially rotated as the probe isretracted.

As the liquid jet cuts in zone Z1, the resulting tissue fragments may becollected in a filter coupled to the ports, the filter being designatedto receive tissue samples from zone Z1. As the liquid jet begins to movefrom cutting in zone Z1 to zone Z2, the apparatus may be configured tohave a new filter receive the samples from zone Z2. Similarly, each timethe liquid jet transitions from one cutting zone to the next, a newfilter may be configured to replace the previous filter, so that tissueremoved from each cutting zone is collected in a separate, appropriatelydesignated filter.

The replacement of filters as the liquid jet transitions from onecutting zone to the next may be achieved in many ways. For example, eachport may be located in a specific cutting zone, and coupled to aseparate channel connected to a separate filter, each filter beingdesignated for a specific cutting zone. Alternately, the channelcoupling the ports to the filter may be further coupled to a pluralityof channels connected to separate filters, and a valve may be disposedat the junction of these channels, such that the valve may be configuredto redirect the removed tissue sample to a different filter as theliquid jet moves from one zone to the next.

The division of the prostate P into 7 cutting zones is for example only.Different numbers of divisions of the prostate P may be used. Forexample, a zone Z1 may be divided into two or more zones based on thedepth of the tissue in relation to the probe (see zones Z1A, Z1B, andZ1C shown in FIG. 9C) and/or or based on radial location (see zones Z1X,Z1Y, and Z1Z shown in FIG. 9D).

Localized tissue and cell removal can help improve the diagnosticanalysis of the removed samples and subsequent treatment of the resectedorgan. For example, in analyzing the removed tissue and cell samples forthe detection of cancer, being able to analyze sample collected fromdistinct zones within the surgical site can provide information on wherethe cancerous tissue is located within the organ. By identifying thelocation of the cancer within the resected organ, therapy may betargeted rather than homogenous. Homogenous treatment may result inexcess and unwanted collateral damage to neighboring tissues, vessels,nerve, as well as remaining non-cancerous tissue. The treatment may beadapted and dosed to reflect the severity of cancer between thedifferent zones of the resected organ.

Localized tissue and cell removal can also help improve aspects of cellharvesting. For example, different areas within an organ can comprisedifferent populations of cells, and being able to harvest cells fromsamples collected from distinct zones within an organ can help improvethe efficiency of harvesting cells of a particular population. In thehuman prostate, prostate stem cells generally reside within the basallayer of the epithelial compartment at a low percentage of about 0.5-1%(Prajapati et al., Biomed Res Int 2013; 2013:107954). Localized tissueand cell removal can help to improve the efficiency of harvestingprostate stem cells for the generation of a pluripotent stem cell line,by enabling a more streamlined harvesting procedure wherein cells areharvested primarily from samples from local zones known to contain thestem cells.

FIGS. 10A to 10D show images of histological sections of prostate tissueremoved from patients using the apparatus 600 as described herein. Thepatients were human subjects treated for prostate hyperplasia as part ofa clinical study. Each figure is a histological section from a differentpatient. Tissue fragments were removed from patients using an apparatuscomprising a probe configured to deliver a liquid jet at the surgicalsite. The histological sections show that the apparatus is capable ofremoving large fragments of tissue with intact structural features,including intact cells 643, as shown by the dark-stained nuclei embeddedthroughout the tissue sections. Histological sections from 38 subjectshave been taken, and all of these histological samples show intact stemcells. Based on the teachings provided herein a person of ordinary skillin the art can conduct testing to show that the nuclei of the cells ofthe tissue fragments comprise stem cells

FIG. 11 shows a method 1100 of removing tissue comprising intact cellsfrom a patient, in accordance with embodiments. At step 1110, tissuecomprising intact cells is removed from the patient as described herein.At step 1112, one or more filters containing the one or more removedtissue samples are sent for post-removal procedures. Post-removalprocedures may comprise, for example, the diagnostic analysis 1120 ofthe tissue samples or the harvesting of cells 1150 from the tissuesamples.

The diagnostic analysis may comprise the analysis of tissue sections1130 or the analysis of intact cells 1140. For tissue section analysis,at step 1132, tissue sections are prepared by fixing and slicing tissuefragment samples. At step 1134, the tissue sections are stained analyzedand analyzed, via method such as histology 1101 or immunohistochemistry(IHC) 1102. For the analysis of intact cells, intact cells are firstremoved from the tissue samples at step 1142, for example viacollagenase digestion of the tissue and centrifugation to separate cellsfrom tissue. At step 1144, cells are cultured and expanded in vitro, andat step 1146, cells are analyzed for the expression of targetbiomarkers, via methods such as RT-PCR and gel electrophoresis 1103,western blotting 1104, immunocytochemistry (ICC) 1105, or flow cytometry1106.

For the harvesting of cells from the tissue samples, cells are removedfrom the tissue at step 1152, for example via collagenase digestion ofthe tissue and centrifugation to separate cells from tissue. At step1154, cells are cultured and expanded in vitro. At step 1156, cellsexpressing target biomarkers are sorted, via methods such asimmunomagnetic sorting 1107 or fluorescence-activated cell sorting(FACS) 1108. At step 1158, sorted cells are further expanded in vitro.At step 1160, the identity and purity of the sorted and expanded cellsis evaluated, by verifying the cells' expression of target biomarkers1162 via methods such as RT-PCR and gel electrophoresis, westernblotting, ICC, or flow cytometry, or by evaluating the ability of thecells to differentiate 1164 in vitro or in vivo.

While preferred embodiments of the present disclosure have been shownand described herein, it will be obvious to those skilled in the artthat such embodiments are provided by way of example only. Numerousvariations, changes, and substitutions will be apparent to those skilledin the art without departing from the scope of the present disclosure.It should be understood that various alternatives to the embodiments ofthe present disclosure described herein may be employed withoutdeparting from the scope of the present invention. Therefore, the scopeof the present invention shall be defined solely by the scope of theappended claims and the equivalents thereof.

What is claimed is:
 1. An apparatus to remove intact cells from asurgical site of a patient, the apparatus comprising: a probe insertableto the surgical site, the probe comprising, a nozzle configured toprovide, to the surgical site, a continuous fluid stream through thenozzle that generates a plurality of pulses comprising cavitations toresect and fragment tissue to create fragmented tissue comprising theintact cells, and a port to receive the fragmented tissue from thesurgical site; a plurality of filters configured to couple to the portin order to receive the fragmented tissue comprising the intact cellsfrom the surgical site; wherein the plurality of filters is configuredto collect the fragmented tissue from a plurality of locations andwherein each of the plurality of filters corresponds to one of theplurality of locations in order to map a sample obtained with one of theplurality of filters to said one of the plurality of locations.
 2. Anapparatus as in claim 1, wherein each of the plurality of filterscomprises a plurality of pores having a plurality a pore sizes andwherein the plurality of pore sizes is dimensioned larger thandimensions of the intact cells in order to collect the fragmented tissuecomprising the intact cells with the filter.
 3. An apparatus as in claim1, wherein the nozzle comprises an area of reduced diametercorresponding to a diameter of the fluid stream released from the nozzleand wherein the nozzle is configured to dissociate the tissue into thefragmented tissue having dimensions sized larger than the reduceddiameter.
 4. An apparatus as in claim 3, wherein nozzle is configured tofragment the tissue with the cavitations of the pulses.
 5. An apparatusas in claim 1, wherein the nozzle and the port are arranged to provide aslurry to the port, the slurry comprising the fragmented tissue andfluid of the fluid stream.
 6. An apparatus as in claim 5, wherein thenozzle is arranged with the port in order to immerse the nozzle in aliquid in order to generate the plurality of pulses with the nozzleimmersed in the liquid.
 7. An apparatus as in claim 1, wherein thenozzle and the port are arranged to provide a closed surgical sitewithin the patient.
 8. An apparatus as in claim 1, further comprising afirst channel extending from a fluid source to the nozzle to generatethe continuous fluid stream and a second channel extending from the porttoward the plurality of filters.
 9. An apparatus as in claim 8, whereinthe fluid source comprises a first pump connected to the first channel.10. An apparatus as in claim 9, further comprising a second pumpconnected to the second channel, the first pump comprising a first flowrate of injected fluid, the second pump comprising a second flow rate,the first flow rate similar to the second flow rate in order to removethe fragmented tissue and injected fluid at the second rate similar tothe first rate of fluid injected into the surgical site with the stream.11. An apparatus as in claim 10, further comprising a fluid reservoir, achannel extending from the fluid reservoir to the surgical site in orderto accommodate differences between the first flow rate and second flowrate and inhibit changes to a volume of a closed surgical site withinthe patient.
 12. An apparatus as in claim 1, wherein the fluid streamcomprises one or more of a liquid or a gas.
 13. An apparatus as in claim1, wherein the continuous fluid stream comprises a liquid stream, theliquid stream comprising one or more of water or saline.
 14. Anapparatus as in claim 1, wherein the cells comprise cells of a glandulartissue of an organ.
 15. The apparatus of claim 1, wherein a flow rate iswithin a range from about 10 ml/min to about 500 ml/min.
 16. Theapparatus of claim 1, wherein an internal nozzle diameter is within arange from about 50 um to 250 um.
 17. The apparatus of claim 1, whereinan angular velocity of the nozzle rotating around an elongate axis ofthe probe is within a range from about 10 degrees per second to 2000degrees per second.
 18. The apparatus of claim 1, wherein a longitudinalvelocity of the nozzle along an elongate axis of the probe is within arange from about 0.01 mm/second to about 50 mm/second.
 19. The apparatusof claim 1, wherein a time of the treatment with the continuous fluidstream is within a range from about 0.1 minutes to about 60 minutes. 20.The apparatus of claim 1, wherein a rotation treatment angle of theprobe about an elongate axis of the probe is within a range from about 0to 360 degrees.
 21. The apparatus of claim 1, wherein a longitudinallength of the treatment area is within a range from about 0.1 mm toabout 300 mm.
 22. The apparatus of claim 1, further comprising a pump todraw injected fluid from the surgical site, wherein the pump comprisesone or more of a vacuum pump or a flow pump.